Tackling foundation years

Modernising medical careers saw the introduction of the Foundation Programme for the training of newly qualified doctors in 2005. The idea is that this training will be a stepping stone bridging the gap between medical training and speciality training.

The Foundation Programme

Medical graduates enter their career with the Foundation Programme. This consists of two years - foundation year 1 and year 2. This replaces the old system of preregistration house officer and senior house officer.¹ Foundation year 1 is equivalent to the old preregistration house officer year and foundation year 2 is equivalent to first year senior house officer. Following these two years, junior doctors will go straight into their specialist training - called 'ST' years.

In order to achieve full registration with the General Medical Council (GMC), medical graduates will need successfully to complete their foundation year 1. Successful completion requires the attainment of several competencies. These competencies are set by the GMC and there is a Foundation Programme curriculum.¹

Objectives of the Foundation Programme

At its core, the Foundation Programme still encompasses the aspects of training that were necessary for preregistration house officers. The focus is on training medical graduates with core clinical skills that are necessary to deal with acutely unwell patients.¹

Starting right

Typically, the two foundation years consist of 6 four-month posts. These usually consist of medical and surgical specialities and other recognised specialities - for example, haematology, anaesthetics, and general practice. When applying for foundation year posts, consider the factors that are most important to you; for example, location, family commitments, and previous jobs you have enjoyed.

Most medical schools allocate tutors who can give advice to final year medical students - make use of them. Alternatively, or additionally, speak to other doctors especially foundation year doctors. It is important to bear in mind that, two years after you start, you are expected to choose a speciality, which may define the greater part of your career working as a doctor. Thus it is paramount that you think seriously about career plans and seek as much advice as you possibly can.

Shadowing

Most hospitals will have 'shadowing' opportunities - this is when final year medical students can shadow the doctor whose job they are about to take over. Make use of these and, whilst on these jobs, try to do the following:

• Orientate yourself - one good way to do this is to get hold of maps which are given for patients. Importantly, locate the canteen, locker room and bathrooms.

• Get a timetable for the firm - for example, consultant ward rounds, registrar ward rounds, radiology meetings, office meetings.

• Introduce yourself to the team - meaning nurses, ancillary staff, ward receptionists, pharmacists; they will become your best friends.

• Try to get to grips with how to book investigations. Most hospitals have electronic patient records and, usually, a password is needed to access these, which will probably not be given until the official start date. However, it is a good idea to ask an already logged on user to sit down and go through the basics with you.

• Take the bleep for the day whilst the outgoing doctor hangs around with you. This is a very good way of getting a 'feel' for the job. It also acts as a way of reducing your nerves on your first formal day.

• Try to go on-call, even if it is only for a few hours so you can at least have some idea of where things are kept in the emergency department/ward. Understand the on-call rota, how to book study leave, etc.

Practising safely

Errors in the workplace have been under much scrutiny in the last few years. It is becoming increasingly apparent that a significant proportion of admissions will be affected by adverse errors directly related to the staff and location. Even more important is acceptance of the fact that these errors are not individual; rather, they are organisational, meaning we must all be vigilant and must always report near misses.² There are several suggested methods to reduce harm, which include simplifying issues, good communication, use of checklists and risk management programmes.²

Prescribing errors have been particularly in the limelight. The causes of prescribing errors are potentially huge, ranging from inadequate knowledge of the prescriber to insufficient information being given to the patient. Electronic prescribing systems have been shown markedly to reduce errors.²

Many errors are preventable and the following is a list of tips for practising safely:²

• Have a low threshold to ask for help - if no one is around then try the on-call team and, failing that, call the consultant. This may seem daunting but it is better to ask rather than jeopardise the patient.

• There will be days when the workload will be high; this may make you feel low but this is a normal reaction. Try to prioritize the jobs - there are some jobs like writing a letter of follow-up for a discharge patient which can be done the next day. Also ask a fellow doctor to help - they may not be that busy and you can always return the favour.

• Use clinical guidelines or speak to someone who can help, eg a pharmacist.

• Always document everything, including writing down blood results (which proves you checked them) and any information when handing over.

• Always take a full medication history if possible - you may need to contact the GP surgery to confirm the medication.

• Errors should be reported and all staff have a responsibility to do so. Errors can also be reported anonymously online to the National Patient Safety Agency.

Things you need to watch out for once you start work

Being a doctor is stressful. It does not matter what level you are at or how experienced you are, there are some days when nothing seems to work. The first most important thing is to talk to someone when things overwhelm you. However, always remember that patient confidentiality is important and must be adhered to at all times.

Unfortunately, for some of us, this will not be enough and things can spiral out of control. Be on the lookout for the following, not only in yourselves but also in colleagues:

Stress - both physical and emotional

Junior doctors suffer from high levels of work-related stress, which can have a marked effect on their well-being as well as affecting patient care. However, stress may also be social relating to lack of time spent with family. Work-related stress can affect health, and result in low morale and motivation, poor decision-making, poor communication, and poor relationships with both colleagues and patients - all of which may negatively affect patient care.³

Doctors should learn to recognise the signs of stress and adopt appropriate coping strategies. Some hospitals provide confidential counselling, psychotherapy, stress workshops, educational seminars and group work to help combat the effects.

Other methods of reducing stress include:

• Working fewer hours with adequate time for breaks. The European Working Time Directive has helped in some part to improve working hours.

• Support from other doctors/staff having similar problems.

• Attending teaching events away from the work base - this helps both education and to improve confidence.

• Social events to unwind; although occasionally simply having a good night's sleep may help.

• Being included in the team and being appreciated as a valuable member of the team.

• Learn to prioritise and accept that there is only one of you and you cannot do everything at once. If you are given more than one job with equal importance ask your senior to take on one job.

• Anticipate jobs (investigation requests, results, fluids, medication charts, etc.) and be organised (pager numbers, extensions, spare supplies for the ward round, etc).

• Indulge in life outside medicine and switch off from work.

• Getting on with other professionals - for example, nurses and physiotherapists, can make a great difference.

Sleep deprivation

Sleep deprivation leads to more mistakes being made. Junior doctors undergoing sleep deprivation have lowered general confidence in their decision-making abilities, suggesting that despite the lack of sleep doctors can still appreciate their deficiencies. Night shifts are often viewed as the most daunting part of the Foundation Programme. In some hospitals night shifts are part of both year 1 and 2 of the Foundation Programme.

Try to get plenty of sleep, especially if you have an early start. Taking 2 hours of sleep before a night shift makes nights easier to tolerate and probably a safer environment for both doctors and patients.⁴

Bullying and harassment

Unfortunately, bullying and harassment are still a problem in the National Health Service.⁵ For doctors this occurs at all levels and involves medical students too. More worryingly, research suggests that women and health workers from black and Asian groups are more likely to undergo harassment.⁶ If you are being bullied or harassed then you must speak to someone urgently. If you are unable to approach your team members then consider discussing it with your senior tutor (usually allocated by the deanery). The only way to stamp out bullying and harassment is to do something about it.

Mental illness and drug abuse in doctors

Doctors are humans nonetheless and some situations will lead us to develop mental illness or misuse of alcohol and drug abuse. Doctors who misuse alcohol are likely to be involved in misuse of drugs such as benzodiazepines. Ironically, doctors who are able to diagnose low mood and depression in their patients, can still fail to identify these very problems in both themselves and in their colleagues.

Some doctors may become temporarily unfit for practice due to illness. It is important to be vigilant to these difficulties in both ourselves and our colleagues. Again speaking to a trusted friend or mentor may help, although it is not easy to admit we have a problem.

At the moment the difficulty is that there is a lot of stigma and taboo associated with this topic. The focus appears to be on 'the bad doctor' but really it needs to be on adequate arrangements for assessment, treatment and rehabilitation. All of this needs to occur without judgement.

Summary

This article has tried to give some advice on how to get through medical training following medical school. Important issues such as stress, bullying and substance abuse have been touched upon. The BMA staff are available to advise and represent individual members facing employment difficulties - for example, pay-related issues or study leave-related issues. There are also other resources available for doctors - some of which are listed in the Internet and further reading section.